Factors associated with adolescent pregnancy among Chepang women and their health-seeking behavior in Ichchhakamana rural municipality of Chitwan district

Adolescent pregnancy is a critical public health issue, particularly in developing regions like Nepal, where it poses significant risks to maternal and child health and perpetuates the cycle of poverty. This study focused on the marginalized Chepang community, which is endangered and faces unique challenges. The study aimed to explore the factors associated with adolescent pregnancy among Chepang women in Ichchhakamana Rural Municipality, Chitwan, Nepal, and also assessed their reproductive health-seeking behavior. A cross-sectional analytical study was conducted with 217 Chepang women aged 15–20 years, and data was collected through face-to-face interviews using a semi-structured questionnaire. The collected data was entered and analyzed using IBM SPSS version 20. Descriptive statistical tools like frequency, and percentage were used to express the results. Pearson chi-square test, Fisher exact test were used for bivariate analysis to determine the presence of association between the dependent and independent variables. Binary logistic regression was used for further analysis. The prevalence of current adolescent pregnancy was 8.3%(18), while one-fourth had experienced prior pregnancies during their adolescence. Factors significantly associated with adolescent pregnancy included lack of education among the women and their mothers, as well as living in joint families. Additionally, number of antenatal visits and consumption of iron tablets seemed to be lower among Chepang women in comparison to the national data. Chepang women had high adolescent pregnancy rates, with low education level and joint family structure being important risk factors for it. They also had inadequate reproductive health seeking behavior. Addressing these problems requires strategies that prioritize education and raise awareness about reproductive health.


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Abstract:
Adolescent pregnancy is a critical public health issue, particularly in developing regions like Nepal, where it poses significant risks to maternal and child health and perpetuates the cycle of poverty.This study focused on the marginalized Chepang community, which is endangered and faces unique challenges.The study aimed to assess the factors associated with adolescent pregnancy among Chepang women in Ichchhakamana Rural Municipality, Chitwan, Nepal, and also explored their reproductive health-seeking behavior.
A cross-sectional analytical study was conducted with 217 Chepang women aged 15-20 years, and data was collected through face-to-face interviews using a structured questionnaire.The prevalence of current adolescent pregnancy was 8.3%, while one-fourth had experienced prior pregnancies during their adolescence.Factors significantly associated with adolescent pregnancy included lack of education among the women and their mothers, as well as living in joint families.
Addressing adolescent pregnancy requires comprehensive strategies that prioritize education and raise awareness about reproductive health among marginalized communities like the Chepang.

Introduction:
Adolescence is a transitional stage of physical and psychological development in the age group of 10 and 19 years. 1 Pregnancy during adolescence is a major contributor of maternal and child mortality, and also leads to a vicious cycle of ill health and poverty. 2 Adolescent pregnancy occurs in estimated 21 million in developing regions and approximately 12 million of them give birth. 2es born to these adolescent mothers account for nearly 11% of births worldwide with 95% occurring in developing countries like Nepal. 3 Two million of these births are from girls under 15 years of age. 4 Pregnancy and childbirth complications are the leading cause of death globally among girls aged 15-19 years , with low-and middle-income countries accounting for 99% of global maternal deaths of women aged 15-49 years. 5Adolescent mothers aged 10-19 years face higher risks of eclampsia, puerperal endometritis and systemic infections than women aged 20-24 years. 6Other consequences are unsafe abortion, still birth and new born deaths. 2 There are many factors and determinants associated with adolescent pregnancy, explained in many literatures. 3,7,8 Ie of marginalized community like Chepang community, factors associated with adolescent pregnancy are household wealth index, ethnicity, religion, sex of the household head, maternal education, literacy level and occupation. 8Nepal Demographic and Health Survey (NDHS) 2016 showed that the country's adolescent birth rate was 88 per 1000 women, with 17% of girls aged 15-19 years already mothers of at least one child. 9This survey also shows that factors like poor household wealth index, being Dalit or Madhesi , and unemployment among women was associated with higher odds of adolescent pregnancies.In contrast, adolescent pregnancy was significantly lower among educated women, and women with access to information on public health issues. 8But there is no study available to compare this data with Chepang women's rate of adolescent pregnancy.
Chepang community is a marginalized and endangered community of Nepal.This community has around 69000 inhabitants in Nepal out of which 8357 population live in Ichchhakamana Rural Municipality of Chitwan district. 10Around 1900 of them are females of reproductive age group (15-49 years). 10An article about adolescent pregnancy in Chepang women in 2016 showed that about 58.1 percent of the respondents have their first child birth in their adolescent age. 11It also showed that complications of adolescent pregnancy among them were preterm labour, prolonged labour, miscarriage and postpartum haemorrhage. 11l Demographic Health Survey (NDHS 2016) estimates show that median age of marriage for women if 17.9 years and the median age of first sexual intercourse is also 17.9 years. 9These are risk factors for adolescent pregnancy.A study in Korak VDC in Chitwan showed that the average age of marriage in Chepang females is 15.48 years and mean age of first child birth was 16.95 years. 11Similarly, another study in Dhading district of Nepal illustrated that the mean age of marriage and first pregnancy was 16.7 years and 17.7 years respectively. 12Additionally, they also have low contraceptive prevalence rate (49.9%) among married Chepang women. 12Studies have shown that there are many strategies adopted by WHO and Nepal to reduce adolescent pregnancy.
A global strategy for women's and children's health launched by United Nations Secretary General in 2010, stresses the importance of addressing the health and welfare of adolescent girls in order to achieve the fifth millennium development goal on maternal mortality reduction. 3WHO has published guidelines on preventing early pregnancy and poor reproductive outcomes among adolescent women in the developing countries like Nepal. 3 Nepal has developed national reproductive health strategy in 1998, in which adolescent reproductive health was identified as a critical component of the integral health package and thus an important indicator of the nations over all health status. 13This study aimed to assess the factors associated with adolescence pregnancy among Chepang women in of Ichchhakamana Rural Municipality, Chitwan.It also assessed their reproductive health seeking behavior.

Study design and population
A cross-sectional analytical study was conducted in three wards of Ichchhakamana Rural Municipality, Chitwan.The data collection was done between July 2021 to October 2021.The study participants were Chepang women aged 15-20 years living at the study site.All women who gave consent to participate in the study were included while those who were unable to answer due to language barrier were excluded from the study.The sample size calculation was done using the formula, sample size=z 2 .p. q/ e 2 .Considering the value of p as 0.17 9 sample size was calculated as 217.
The study started with purposive selection of Ichchhakamana Rural Municipality as the study site.
The municipality consists of seven wards.At the first stage, three wards were chosen randomly for the study using lottery method.Next, the study site was visited and the proposed participants in the Chepang community were informed about the objectives of the research and its expected outcome.After getting approval for engagement, the required sample size was taken equally from all wards using sampling intervals (72 from ward 1 and 3 and 73 from ward 6 ).First house from respective ward was selected randomly and rest of the houses were selected consecutively until required sample size was reached.If more than one, participant meeting the eligibility criteria were found at selected households then all of them were interviewed.

Study variables and data collection
The dependent variable was adolescent pregnancy while independent variables included sociodemographic, sexual and reproductive characteristics of the participants.Other variables included health seeking behavior like number of antenatal visits, age at first intercourse etc.
Adolescent Pregnancy was defined as any women aged 15-20 years who have had a live birth within the last 1 year or women aged 15-19 years who are pregnant with their first child during the time of the study.
The data was collected with the help of a questionnaire by using face to face interview technique.
The questionnaire consisted information regarding socio-demographic details, sexual and reproductive characteristics, health seeking behaviour etc. Extensive literature review was done for making the questionnaire.The questionnaire was shared with content experts for content validity.Face validity of the questionnaire was maintained by discussion with colleagues.
Pretesting was done in 10 % of sample size (among the population in the selected ward who do not belong to Chepang ethnicity) and necessary modifications were made to the questions.As the questionnaire demands recalling information for the past 1 year, there is a chance of recall bias.

Statistical analysis
The collected data was entered and analyzed using IBM SPSS version 20.First of all, the prevalence of adolescent pregnancy was calculated.Descriptive statistical tools like frequency, and percentage were used to express the results.Pearson chi-square test, Fischer exact test were used for bivariate analysis to determine the presence of association between the dependent and independent variables.Crude odds ratio (COR) at 95% confidence interval (95% CI) was calculated to see the magnitude of association with independent variables.In multivariate analysis, binary logistic regression was carried out.Independent variables associated with current pregnancy status with a significance level of less than 0.20 (p-value< 0.20) were adjusted among themselves to calculate corresponding adjusted odds ratio (AOR).All tests were done with the significance level set at 5% (p-value <0.05).In the assessment of multi-collinearity, the Variance Inflation Factor (VIF) was determined to be less than 10.This confirms the absence of any interconnection among the independent variables.

Ethical Consideration
Ethical approval was taken from Nepal Health Research Council (NHRC).The office of Ichchhakamana rural municipality was contacted and a letter of support for community engagement was obtained.After this, the ward chairpersons of the selected wards (wards 1, 3 and 6) were contacted and permission was taken to conduct the research.Next, a written consent was taken from the respondents or their parents.If the respondents were married at the time of interview, written consent was taken from the respondents themselves.However, if the respondent was unmarried, written consent was taken from the parent/guardian.The respondents' participation in the study was voluntary and their confidentiality was maintained.The information is kept safely in the computer with proper password to disallow any fallacy in conduction of the study.

Results
There were total 217 participants.The features of the participants are as follows:

Socio-demographic characteristics of the participants
They were aged between 15 to 20 years of age.Their mean age was 17.6 years with standard deviation of 1.7 years.Most of the participants were aged 18 years (19.8%)followed by 20 years of age.(Table 1) Furthermore, most of the participants were Hindu (85.3%) and majority of the women had studied till Primary level (67.7%).(Table 1) Similarly, 30 % were involved in farming.
(Table 1)  1) The most common reason behind not using contraceptive methods were its use not being feasible (42.7%), desire to get pregnant (36%) and lack of awareness (15.7%) about the methods.

Features of Current Adolescent Pregnancy:
Among the participants, 8.3% were currently pregnant.Almost all except one pregnancy was unplanned.But all of the pregnant women were happy about their pregnancy.While 72% of the pregnant women considered amenorrhea as an indicator of pregnancy, the rest relied on health checkup.Amongst the pregnant, most (44.5%) were in their second trimester.(Table 2) Furthermore, 50% of them were taking iron tablets, but only 22% were taking calcium tablets.
(Table 2) Regarding the tests done during pregnancy, 83.3 % of the women had physical examination,66.7%had a urine examination, 22% had an ultrasonography, 11 % had done blood tests , but only 11 % of them had done all of these.

Features of previous adolescent pregnancy:
Almost a quarter (24%) of the participants had a previous pregnancy.Among them, 79 % had live births and majority of them did not have any health issues among mothers (90.2%) or the neonates (82.7%) at the end of the pregnancy.(Table 3)

Association of adolescent pregnancy with socio-demographic and family variables:
Higher percentage of participants who were pregnant belonged to Hindu religion.But this relationship was not statistically significant.(Table 4).The study showed that those adolescents who had never been to school had 2.9 times more chance of being pregnant compared to those who had been to at least primary school (COR (95%CI): 2.9[1.1-7.9]) and this relationship was statistically significant.(p<0.05) (Table 4).Similarly, those who lived in joint families had a higher chance of being pregnant compared to nuclear families (COR (95%CI): 4.8 [1.5-15.0])and this relationship was also statistically significant (p<0.05)(Table 4).Among the pregnant adolescents 197 most had females as head of the family and lived in families who earned less than NRs.In our study, the prevalence of adolescents who were currently pregnant was 8.3%.This is in contrast to the results of a Systematic Review and Meta-analysis conducted in Nepal which showed the prevalence to be a bit higher (13.2%). 14Similarly, a report by UNICEF showed that, in South Asia region adolescent marriage and pregnancy was highest among Nepalese and Bangladeshi girls. 15Nevertheless, it is noteworthy to highlight that approximately one-fourth of the participants disclosed a history of prior pregnancies.Given the age range of our participants, spanning from 15 to 20 years, this observation suggests that these women experienced teenage pregnancies at some stage during their adolescence.
Our study showed that those adolescents who had never been to school had 2.9 times more chance of being pregnant compared to those who had been to at least primary school (COR (95%CI): 2.9[1.1-7.9]).This finding is supported by World Bank estimates which states that more education for girls can result in delayed pregnancy. 16Similarly, several other research has illustrated that marrying at a young age and early pregnancy were both results of low level of education among the adolescent girls. 15,17,18 ducation empowers women by providing them with knowledge about reproductive health and family planning, leading to more informed choices. 19This may result in delayed marriages, encourage aspirations beyond early motherhood, and enhance access to resources and healthcare.
Furthermore, in our study those who lived in joint families had a higher chance of being pregnant compared to nuclear families (COR (95%CI): 4.8 [1.5-15.0])and this relationship was also statistically significant (p<0.05)(Table 7).The higher likelihood of pregnancy in joint families can be attributed to different reasons.Residing in joint families can result in limited personal freedom and the perpetuation of traditional beliefs, 20 often leading to early age at marriage and childbirth.However, it also offers the advantage of a larger support system and sharing of responsibilities, 21 which may promote pregnancies by creating a more conducive environment for giving birth to and raising children.
Among the pregnant adolescents most had females as head of the family and lived in families who earned less than NRs.15,000.But these associations were not statistically significant.
Furthermore, adolescents with mothers who never went to school had 3.6 times more risk of being pregnant compared to those who had at least primary level education (COR, 95% CI: 3.68 [1.17-11.57])and this association was statistically significant (p<0.5).Mothers' education has been associated with reduced level of fertility and increased age at first birth for her offspring. 22Hence, this heightened risk of pregnancy among the adolescents may be attributed to limited knowledge of reproductive health among the uneducated mothers.
Our study had few limitations.Since participants had to recollect memories in order to respond to the questions, a potential recall bias is there.Similarly, due to the design of our study we were unable to assess the temporality of association.

Conclusion:
Teenage pregnancy was high among the Chepang women in Ichchhakamana Rural Municipality.
It was associated with low level of education among women and their mothers and their family type.Addressing adolescent pregnancy requires comprehensive strategies prioritizing education and reproductive health awareness.
Municipality.Their authorization for data collection and cooperation are highly acknowledged and appreciated.
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Table 1 : Socio-demographic characteristics of the participants 157
159More than half (54.8%) of the families were nuclear.(Table1)In about three quarters (73.3%) of 160 the families, the head of the household was a male.Additionally, 64 % of the families had an 161 income of more than NRs.15,000.(

Table 1 )
Similarly, almost half of the participant's mother had 162 never been to school while the rest had studied till Primary level.(

Table 1 ) 163 Reproductive and sexual health characteristics of the participants: 164 Sexual health characteristics:
165Almost half (47.5%) of the participants were married and majority (28%) of them were married at 166 18 years of age.(

Table 1 )
The mean age of marriage was 16.84 years with standard deviation of 167 1.52 years.About 48% of the participants stated that they have been sexually active.(Table1)For majority of them (64.4%), the age of first sexual contact was 15 to 18 years and only about 14% had used contraceptive devices.(Table

Table 4 : Association of adolescent pregnancy with socio-demographic and family variables: 205
15,000.